LID: Exam of Wounds

Layers of skin from outermost to innermost

1.) epidermis (outermost)

2.) dermis (underlying layer, connected to epidermis via basement membrane)

3.) hypodermis (subcutaneous layer)

Layers of the epidermis from superficial to deep

1.) stratum corneum: several layers of ead skin cells at the surface

2.) stratum lucidum: clear/translucent layer only in the soles of feet/palms of hands

3.) stratum granulosum: cells undergo differentiation as they approach the surface; creates barrier to moisture loss and foreign material

4.) stratum spinosum: thickest layer, protein synthesis occurs here

5.) stratum basale: production of epidermal cells, keratinocyte mitosis occurs in the stratum basale and through stratification cells migrate through the layers and at the stratum corneum become known as corneocytes that form the protective outer skin layer

What type of cells compose the layers of epidermis?

-keratinocytes

-melanocytes

-Langerhands cells

-Merkel cells

What does the basement membrane do?

-holds the epidermis and dermis together

-allows nutrients from the dermis to pass through to the avascular epidermis

What is the dermis made of? What is its function?

-connective tissue layer that binds the epidermis to the hypodermis

-includes the papillary dermis (fibroblasts, mast cells, macrophages) and the reticular dermis (T1 collagen, vasculature, nerve endings, glands, hair follicles)

-fx: gives flexibility and elasticity to the skin

-fx: contains hyaluronan, which contributes to cellular proliferation/migration which is important for the wound healing process

T/f the dermis contains hyaluronan, which contributes to cellular proliferation/migration which is important for the wound healing process

True

What is the hypodermis (subcutaneous) made of? What is its function?

-composed of loose CT, vascular supply, and adipose cells

-fx: binds skin to underlying structures

-fx: allows skin to move freely over underlying fascia, muscles, and CT

Functions of skin

-sensation

-barrier to fluid loss

-immunity: keeps out bacteria/debris

-thermoregulation

-protection from UV rays

-vit D synthesis/storage

-individual appearance

What are the phases of wound healing?

1.) hemostasis

2.) inflammation

3.) proliferation

4.) maturation and remodeling

What is hemostasis (wound healing)?

-1st phase of wound healing

-small vessels vasoconstrict to slow blood flow and platelets adhere to the endothelium and combine with fibrin to form stable clots

-platelets release growth factors that lead to fibroblast formation and eventually build the scaffold for cellular components that will be active during the inflammatory phase

-macrophages and neutrophils work to kill bacteria

What does inflammation involve as part of wound healing?

-2nd phase of wound healing

-continued cellular attack on microbes, phagocytosis of cellular debris (autolytic wound debridement), and neo-angiogenesis (early formation of new blood vessels and granulation tissue)

What is proliferation (wound healing)?

-3rd phase of wound healing

-angiogenesis, fibroplasia (collagen formation), matrix deposition, and re-epithelialization (epidermal migration)

What is maturation and remodeling (wound healing)?

-4th phase of wound healing

-dermal regeneration, wound contraction, increase in tensile strength with integration of the dermal-epidermal junction

-healed wounds have 80% the original tensile strength

What is a chronic wound?

-does not follow normal healing trajectory; may persist for months to years

-chronic inflammatory state prevents cell proliferation

-presence of pathogens and foreign body/debris

-underlying disease process

-can include diabetic, arterial, venous, PI, non-healing surgical wound

-diminished perfusion/tissue oxygenation

-impaired nutrition

-mechanical forces on the wound

What do you document for wound assessment?

-location

-dimensions

-tissue types

-drainage

-odor

-wound edges

-peri-wound skin

-edema

-infection

-pain

What should you include in wound assessments?

-subjective, wound history

-medical record review

-medications

-document: location, dimensions, tissue types, drainage, odor, wound edges, peri-wound skin, edema, infection, pain

T/f location is related to wound etiology

True

How can wound dimensions be documented?

-outcome measures: improvement or lack of response to interventions

-perpendicular (ruler) method: lengthxwidth, depth

-clock method: orientation 12 (cephalic), 6 (caudal), 3 (right lateral), 9 (left lateral); used to identify locations of tunneling/undermining

-tracing

-photography

-planimetry: uses software to calculate wound dimensions from digital photography

T/f progress toward healing is indicated by reduction in wound dimensions

True

How is the perpendicular (ruler) method performed?

-lengthxwidth: measure longest length and then widest width perpendicular to the length (can result in overestimation)

-depth: measure at deepest part of wound perpendicular to wound surface

-volume = length x width x depth

How is the clock method performed?

-orientation based on clock

-can be applied to surface area measurement to ensure consistent measurement location

-used to identify locations of tunneling/undermining

Tunneling vs. undermining vs. sinus tract

-undermining: destruction of subcutaneous tissue that extends from wound edge below the skin where the skin is detached from the underlying structures

-tunneling: tissue destruction that results in a connection between two wounds under the skin

-sinus tract: extension from the edge of the wound along a fascial plane that has a small opening and connects to deeper area of tissue loss

Types of wound tissue:

-eschar: non-viable, black to brown/gray/yellow/tan, hard and dry/leathery

-slough: non-viable subcutaneous tissue beneath eschar or on wound surface, soft, yellow

-granulation tissue: viable, beefy red

-muscle, bone, tendon/ligament, adipose

-foreign body: sutures, staples, dressing material, debris

Eschar

-non-viable

-ranges in color from black to brown, gray, yellow, or tan

-may be hard and dry or leathery

Slough

-non-viable subcutaneous tissue that can be found underneath eschar or on the surface of a wound

-usually soft with no real texture

-yellow

-results from body's own autolytic debridement process (phagocytosis)

Granulation tissue

-beefy red mixture of ECM and capillaries that fills in the wound

What should you measure when assessing wound drainage?

-volume: none, scant, minimal, moderate, heavy, copious

-volume should decrease over time as wound progresses toward healing

Wound drainage consistencies: serous vs. serosanguinous vs. sanguineous

-serous: clear and watery (i.e. blister fluid, weeping)

-serosanguinous: pink serous drainage with presence of minimal RBCs

-sanguineous: thin, bloody drainage

Wound drainage consistencies

-serous

-serosanguinous

-sanguineous

-exudate

-purulence

-seropurulence

Wound drainage consistencies: exudate vs. purulence vs. seropurulence

-exudate: pale yellow made up of serous fluid, dead cells, and debris with high protein content

-purulence: thickened and with odor that contains debris and bacteria (pus) that indicates colonization or infection (yellow, blue, green)

-seropurulence: slightly thicker yellow drainage that occurs when bacteria is destroyed by the body

Why is odor almost always present when dressing is removed from a wound?

-odor d/t interaction between the wound bed, drainage, air, and the dressing

-persistent odor after wound cleansing is related to infection, malignancy, and necrosis present in the wound (concerning)

T/f odor right after dressing removal is normal, but persistent odor after wound cleansing is related to infection, malignancy, and necrosis present in the wound and is concerning

True

What are some common wound edge presentations?

-regular/even (circular)

-irregular/uneven (curving, irregular border)

-rolled (epibole)

-detached

-hyperkeratosis/callus

-epithelialization

Rolled (epibole) wound edges

-cells are unable to migrate and attach to deeper wound bed, thus stopping the process of epithelial migration

Detached wound edges

-wound edge is unattached to wound bed (undermining, tunneling)

Hyperkeratosis/callus wound edges

-seen most commonly in diabetic foot ulcers or areas of high friction/repeated trauma

Epithelialization wound edges

-in typical healing progression, new skin (pink) can be seen forming at wound edges

What are potential colors of periwound skin and what do they indicate?

-erythema: red, blanchable or non-blanchable, indicative of inflammation, infection, PI, etc.

-cyanosis: blue to purple, indicating lack of bloodflow/ischemia

-dark red to purple: capillary bleeding as a result of tissue trauma (i.e. deep tissue injury)

-hemosiderin staining: brownish-purple discoloration from dead RBCs trapped in the interstitium as a result of venous insufficiency

-blanched: white/lighter skin relative to natural color most often seen in chronic venous insufficiency

-jaundice: yellow discoloration d/t hyperbilirubinemia associated with underlying disease process

What are potential periwound skin textures and what do they indicate?

-thin, shiny, hairless (PAD)

-thick, rough, dry (chronic venous insufficiency)

-indurated (hard and firm from underlying fibrosis, inflammation, or infection)

-fibrotic (seen with chronic edema/lymphedema)

-macerated (wet, wrinkled "pruney" appearance)

What is thin, shiny, hairless periwound texture associated with?

PAD

What is thick, rough, dry periwound texture associated with?

Chronic venous insufficiency

What is indurated periwound texture associated with?

Hard and firm from underlying fibrosis, inflammation, or infection

What is fibrotic periwound texture associated with?

Seen with chronic edema/lymphedema

Describe macerated periwound texture

Wet, wrinkled pruney appearance

What does a non-invasive vascular assessment include?

-pulses/palpation

-doppler exam

-capillary refill time

-rubor of dependency: screen for ischemia/PAD

-venous duplex: DVT

-ABI: degree of PAD

-toe pressures: PAD

-TcPO2: healing potential

-arterial duplex: anatomic blood flow assessment

What does rubor of dependency test for?

-screen for ischemia

-elevate to induce pallor, then place dependent

-increased time to regain color and dark red color indicates PAD

What capillary refill time is normal?

-normal=<3sec

-will be prolonged with small vessel disease

T/f presence of signal on a doppler exam is not indicative of normal bloodflow

True

What toe pressure is normal vs. indicative of PAD?

-normal = >50 mmHg

-PAD = <30 mmHg

T/f TcPO2 of 60-90 mmHg is normal

True

How do you take an ABI assessment?

-place patient in supine

-obtain brachial systolic pressure from both arms and use the higher of the two

-obtain systolic pressure of the dorsalis pedis and posterior tibial arteries

-calculate the ABI: ankle/brachial

T/f compression is safe to use on individuals with ABI=0.8-0.9 (mild arterial disease)

True

T/f patient must have ABI>0.7 for debridement

True

T/f for ABI 0.6-0.8, use caution with compression; ABI<0.6 compression is contraindicated

True

T/f IM claudication usually begins at <0.8 ABI

True

T/f 4+ sites noted to be insensate on Semmes-Weinstein Monofilament Testing indicates lack of protective sensation

True